About 525,000 more deaths occurred among US adults in 2023 than would be expected had pre-2010 mortality trends continued. More than 90 percent of these deaths occurred among individuals without a Bachelor's degree and were largely caused by cardiovascular diseases, underscoring how educational attainment can influence individuals' health opportunities and outcomes.
Cardiometabolic diseases such as cardiovascular disease and type 2 diabetes have emerged as some of the key drivers of worsening mortality rates in the United States over the last 15 years. People with limited education are feeling the brunt of this crisis, according to a new study by Boston University School of Public Health (BUSPH), the University of Helsinki, and the University of Minnesota.
For both men and women without a Bachelor's degree (BA), mortality between 2011-2023 was markedly higher than would have been expected had death rates from 2006-2010 continued. Among 564,855 excess deaths in 2023 alone, 481,211 occurred among people without a BA—a 26 percent increase in mortality among this population, compared to pre-2010 trends. In contrast, mortality only increased by eight percent among people who received a BA. The study was published in JAMA Health Forum .
"While much attention has focused on how the COVID-19 pandemic led to life expectancy declines and excess mortality , our study shows that the United States was already experiencing an increasing number of excess deaths before the pandemic," says study lead author Dr. Eugenio Paglino, postdoctoral researcher at the Helsinki Institute for Demography and Population Health at the University of Helsinki. "The pandemic further exacerbated these trends, with excess deaths peaking in 2021. However, even after COVID-19 mortality declined in 2023, excess deaths remained substantially higher than in the pre-pandemic period, highlighting the importance of looking at long-term mortality trends to uncover the mechanisms behind current developments."
The findings underscore the urgent need to address cardiometabolic health and chronic diseases nationwide, particularly the social and structural factors that might explain why people with less education disproportionately experience these adverse health outcomes.
"The United States is facing a crisis of deteriorating mortality that is largely falling on the shoulders of those with less education," says study senior and corresponding author Dr. Andrew Stokes , associate professor of global health at BUSPH. "Living in rural areas, having a lack of access to healthy foods and good nutrition, working in precarious employment sectors—these are the things that make it difficult to eat well, sleep well, and exercise. Education fundamentally structures people's work opportunities, and having less of it sets people up for a lot of downstream consequences that make it difficult to maintain good health."
For the study, Dr. Stokes and colleagues from the University of Helsinki and the University of Minnesota utilized national mortality and education data to examine 47, 545, 611 deaths among US adults ages 35 and older from 2006-2023, categorizing 2011-2023 as the pre-pandemic, pandemic, and post-pandemic periods.
While less pronounced, circulatory diseases were also the leading cause of excess deaths among adults with a BA or equivalent degree.
"Despite decades of progress in prevention and treatment, cardiovascular diseases (including heart disease and stroke) remain the leading causes of death and major disability in the US and worldwide," says Dr. Donald Lloyd-Jones, director of Boston University's Framingham Center for Population and Prevention Science and primary investigator of the Framingham Heart Study , the longest-running heart disease study in the US. Dr. Lloyd-Jones, who is also the Alexander Graham Bell Professor and section chief of preventive medicine and epidemiology at BU Chobanian & Avedisian School of Medicine, was not involved in the study. "We know that the social drivers of health, including socioeconomic position, neighborhood environment, and, especially education, have a major impact on the predisposing risk factors for cardiovascular disease such as adverse diet, obesity, diabetes, blood pressure, and blood lipids. These findings reinforce and quantify the role that education can play in equipping people to manage their health and extend their longevity."
Diabetes was also a top 2023 contributor to excess deaths among men and women without a BA, and to a lesser extent, those with a BA. The researchers cite a range of factors that have led to an increase in unhealthy food consumption, from effective marketing and advertising of ultra-processed foods to a lack of access to affordable, nutrient-dense foods.
Of note, the findings also showed that drug overdoses were a significant contributor to excess deaths among men with less education, but were much less pronounced among men with more education.
"This observation reflects the downstream consequences of prescription drug use, which led to widespread drug reliance and overdose in the early 2000s, before translating into the use of heroin, fentanyl, and other products that were more readily available during that period," Dr. Stokes says. "The fact that drug poisonings were still a major cause of excess deaths for men without a BA in 2023 points to the ongoing role of deaths of despair in US mortality."
"This work is a clarion call for us to understand the health threats facing Americans with less education," says Dr. Maria Glymour, chair and professor of epidemiology at BUSPH, who was not involved in the study but has studied how education is a predictor of health. "The mortality differences reported here suggest that we need to consider the 'causes of the causes' of social inequalities. History demonstrates it is possible to either shrink or magnify these disparities via public health and policy actions."
The researchers did observe a few promising trends in mortality. Among women with a BA, deaths due to cancer and other external causes (such as accidents and violence) decreased in 2023, compared to totals between 2006-2010.
"If we had simply maintained the progress we were making for each of these education groups 20 years ago, there are half a million Americans who died in 2023 who wouldn't have died," says study coauthor Dr. Elizabeth Wrigley-Field, associate professor of sociology at the University of Minnesota, Twin Cities. "Almost 92 percent of them didn't have a college degree. The fact that the causes of these deaths span such different causes, including cardiovascular diseases, drug overdoses, and diabetes, tells us that there is a really deep divide in who benefits from health progress."
One of the most important ways in which education matters is the kind of work it gives people access to, she adds. "We hope these results will contribute to a conversation about the ways that American workplaces aren't always conducive to good health, and what would allow American workers to live longer lives."
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About Boston University School of Public Health
Founded in 1976, Boston University School of Public Health is one of the top ten ranked schools of public health in the world. It offers master's- and doctoral-level education in public health. The faculty in six departments conduct policy-changing public health research around the world, with the mission of improving the health of populations—especially the disadvantaged, underserved, and vulnerable—locally and globally.
